Substance Abuse and Brain Injury Anastasia Edmonston MS CRC TBI Projects Director Maryland Mental Hygiene Administration

Substance Abuse and Brain Injury

Anastasia Edmonston MS CRCTBI Projects DirectorMaryland Mental Hygiene Administration

The Elephant In the Room:Brain Injury and Substance Abuse

Overview

Overview of TBI-Screening for TBIBriefly: Facts and Figures-What is

The Problem?Lessons Learned-What brain injury

professionals have and haven’t done to address the Brain Injury/ Substance Abuse Connection

Overview

Utilities for Community Professionals-Ohio Valley Model

Substance Abuse Screening tools Modifying Substance Abuse

treatment and intervention strategies for individuals with brain injuries

Definitions: How brain injury may be defined in the Medical Record

Acquired Brain Injury is an insult to the brain that has occurred after birth, for example; TBI, stroke, near suffocation, infections in the brain, anoxia

Diffuse Axonal Injury the tearing and shearing of microscopic brain cells

Traumatic Brain Injury is an insult to the brain caused by an external physical force

Incidence of TBI CDC 2004

In the United States, at least

1.6 million sustain a TBI each year

Incidence of TBI …….Of those 1.6 million.. CDC 2004

51,000 die;290,000 are hospitalized; and

1,224,000 million are treated an released from an emergency department

Annual Incidence of TBI with DisabilityAN ESTIMATED 124,000 American civilians

Cited by Jean Langlois ScD,MPH NASHIA Conference 2007Preliminary findings as analyzed by Selassie, et. al

Service Members returning with TBIRevised Numbers 3.3.09 Gregg Zoroya, USA Today 3.4.09 & MSNBC.com 3.4.09

Pentagon estimates up to 360,000 Iraq and Afghanistan vets may have suffered brain injuries

Of the 360,000 are 45,000 to 90,000 whose (more severe) symptoms persist & require specialized care


These numbers are based upon Military health-screenings that show 10% to 20% of returning troops have suffered at least a mild concussion

Among them 3%-5% with persistent (concussive) symptoms that require specialists, e.g. ophthalmologists to deal with vision problems


The estimate represents 20% of the 1.8 million troops who have served in Iraq and Afghanistan

According to Lt. Col. Lynne Md. Lowe of the Army surgeon general’s office, the Army spent $242 million in 2008 for staff, facilities, and programs to serve brain injured troops

Polytrauma “a unique constellation of injuries” Archives of Phys Med Rehab 1/08 Friedemann-Sanchez G. et al

AmputationsCraniectomiesBurnsTraumatic Brain InjuryVision problems are being report with

greater frequency, according to the Blinded Veterans Association 75% of those with TBI have visual complaints

Causes of TBI CDC 2006

Falls, 28%

Motor Vehicle-Traffic, 20%

Struck By/Against, 19%

Assault, 11%

Unknown, 9%

Other, 7%

Pedal Cycle (non MV), 3%

Suicide, 1%

Other Transport, 2%

The Scope of the ProblemCenters for Disease Control 2004

Approximately 475,000 TBIs occur among children ages 0-14

ED visits account for more than 90% of the TBIs in this age group

The two age groups at highest risk of traumatic brain injury are ages 0-4 and 15-19

About 3.17 Million Americans live with the consequences of traumatic brain injury(that we know of-those who are counted)Centers for Disease Control (2008)

MD TBI Project 2006-2009Consumer Profile (182 consumers, recipients of community based resource coordination services)

Men (@56% of consumers)On average 9 years post injuryMental Health issues 42%Drug and Alcohol use and abuse 28.%Homelessness/danger of

homelessness 6%86% unemployed@15% of consumers have had some

kind of forensic involvement

There are many we don’t count425,000 treated by MD’s in office visits90,000 treated in other outpatient

settingsUntold numbers who fall, are assaulted,

play, sports etc.360,000 service members returning from

Iraq & Afghanistan reporting a “probable” TBI=20% who have served Langlois et. al., Rand Corporation, 2008, cited by Wayne Gordon Ph.D, Webcast, Maternal and Child Health Bureau 5.22.08 at www.mchcom.com

“Reframed, the numbers nauseate. In America alone, so many people become permanently disabled from a brain injury that each decade they could fill a city the size of Detroit……...

….Seven of these cities are filled already. A third of their citizens are under fourteen years of age.”

From Head Cases, Stories of Brain Injury and its AftermathMichael Paul Mason2008 published by Farrar, Straus and Giroux

The Scope of the Problem

Distribution of Severity: Mild injuries = 80%

Loss of consciousness <30 min. Post traumatic amnesia < 1 hour

Moderate = 10 - 13%Loss of consciousness 30 min.-24 hrs. Post traumatic amnesia 1-24 hrs

Severe = 7 - 10% Loss of consciousness > 24 hours. Post traumatic amnesia >24 hrs

The Importance of Post Traumatic Amnesia

PTA is the period of time after injury when a person is unable to lay down new memories…for example

“That first morning, wow, I didn’t want to move, I was thankful that nothing’s broken, but my brain was all scrambled” Ryan Church, NYT 3/10/08

“All he remembers from the collision with Anderson is the aftermath, being helped off the field by two people, although he said he did not know who they were until he saw a photograph later” Ben Shpigel NYT reporter

What happens in a TBI?

Mechanism – Acceleration/Deceleration Differential movement of partially

tethered brain within the skullResults in:

Bruising of the brain surfaceagainst rough areas of the skull

Stretching and twisting of nerve axons

Skull AnatomyThe skull is a rounded layer of bone designed to protect the brain from penetrating injuries.

The base of the skull is rough, with many bony protuberances.

These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration.

Dr. Mary Pepping

Primary Injuries…

Coup-Contra Coup

Primary Injuries…

Diffuse Axonal Injuries

Rotational forces onthe brain cause the stretching, snapping and shearing of axons

The Developing BrainChildren’s brains do not reach their

adult weight of 3 pounds until they are 12 years old

The brain, and most importantly the brain’s frontal lobe region does not reach it’s full cognitive maturity till individuals reach their mid twenties.

The frontal lobe is very vulnerable to injury

Take Home Message

Kids “Grow” Into Their Brain Injuries G. Gioia Ph.DChildren’s National Medical Center

Other potential Neurotoxins that may impact the brain

Exposure to lead paintRegarding exposure to alcohol in utero,

according to Dr. Jacobson of Wayne State University “We found more serious cognitive impairment in relation to alcohol than cocaine or other drugs, including marijuana and smoking” From “Fetal Brains Suffer Badly From Effects of Alcohol” NYT 11.4.03

This is important to keep in mind because…..

The Adult you are serving in your program may have suffered a brain injury as a child

Concussion and Multiple Concussion can lead to...

Elevated rates of depression (most common mental health diagnosis after brain injury)

alcohol and drug abuse

Concussion and Multiple Concussion can lead to...

elevated rates of panic disorder, obsessive compulsive disorder

These are among the findings a 2000 epidemiological study by Silver that found of 5000 individuals interviewed, 7.2% had experienced a blow to the head followed by loss of consciousness or period of confusion

Take Home Message

“Unidentified traumatic brain injury is an unrecognized major source of social and vocational failure”Wayne Gordon, Ph.Dquoted in the Wall Street Journal 1.29.08

Possible Changes

Physical: Motor skills, vision, speech, fatigue, seizures, hearing, etc

Cognitive: Memory, concentration, “executive skills”, receptive & expressive language, impulse control, and the ability to multitask and think flexibly

Behavioral and Personality: depression, emotional discontrol, reduced frustration tolerance, substance abuse

Lack of Awareness

A common and difficult to remediate hallmark of a brain injury

Recommendation: All Human Service Providers Screen Consumers for a History of Brain Injury

Why Screen?What other TBI Screening efforts have found

Impact of TBI in Adolescent Treatment Programs 2005 study by Corrigan et.al

189 adolescents receiving residential SA tx were screened for a hx of brain injury

TBI with LOC reported by 23% of residents

13% reported a moderate or severe TBI

TBI related symptoms included:

HeadachesDizzinessMemory problems Fatigue Difficulty controlling temperBeing easily stressedHaving problems with school work

The Take Home Message...“Having a TBI with loss of consciousness was significantly associated with being more likely to be dependent on both alcohol and other drugs, to having experienced a drug overdose with loss of consciousness, being in special classes and having a seizure disorder……...

The Take Home Message...

…….There were trends toward TBI with loss of consciousness being associated with having a learning disability, having violence-related convictions, and receiving psychiatric outpatient services. Among the later, persons with TBI were more likely to be treated for attention deficit hyperactivity disorder, anger management and conduct disorders.”John Corrigan Ph.D

Brain Injury in the Correctional Setting-Nationally CDC website 2008

According to jail and prison studies,25-87% of inmates report having experienced a TBI-this compared with 8.5% of the general population

Prisoners with a history of TBI may also experience mental health disorders (including; severe depression, anxiety, substance abuse)

Brain Injury in the Correctional Setting-Nationally CDC website 2008

Woman inmates who are convicted of a violent crime are more likely to have sustained a pre-crime TBI or some other form of physical abuse

Women with substance abuse disorders have an increased risk for TBI compared with women in the general population

In Maryland- Screening Results from the MD TBI Post Demo II Project-2005

Summary of TBI Incidence Among all Screened at 7 public mental health agencies in Frederick and Anne Arundel counties

N=190 39% no reported history of TBI (78) 58.94% of individuals with a history of TBI

(112) 35.78% of individuals with a history of a

single incidence of TBI (68) 23% of individuals with a history of 2 or

more TBIs (44)

Details- Anne Arundel County Detention Center 2005

N=41 Single TBI= 16 2 or more incidents of TBI= 14 No history of TBI= 11 73% screened reported a history of TBI

Washington County Detention Center 2008

N=25 (16 male, 9 female) 22 reported possible TBI(s) Single TBI=10 2 or more incidents of TBI= 12 No History of TBI =3 88% screened reported a

history of TBI

Brain Injury & ViolenceDomestic Violence

Greater than 90% of all injuries secondary to domestic violence occur to the head, neck or face region (Monahan & O’Leary 1999) Adapted from The Alabama Department of Rehabilitation Services DV Training

Corrigan et.al., (2003) found that of 167 individuals treated for domestic violence related health issues, 30% experienced a loss of consciousness on at least one occasion, 67% reported residual problems that were potentially TBI related

Valera and Berenbaum, (2003) assessed 99 battered women. Of these, 57 had brain injured related symptomatology

Homelessness & Brain InjuryA little studied population, however…..

A University of Miami study found that 80% of 60 homeless individuals had high incidence of neuropsychological impairment

Researchers in Milwaukee found possible cognitive impairment in 80% of 90 homeless men evaluated.

Dr. LaVecchia of the MA Statewide Head Injury Program reported in 2006 that of 140 homeless individuals evaluated, 83.6% of males and 16.4% of females had an acquired brain injury

Other studies in the UK and Australia show similar rates of brain injury among homeless individuals

Homelessness: 10.7.08 Canadian Medical JournalHwang et.al

904 homeless individuals surveyed

Addiction Severity Index usedTBI Screened, >30 minutes

moderate/severePhysical & mental health

assessed

Findings

Hx of moderate-severe TBI associated w/ increased likelihood of seizures

Mental Health problemsDrug problemsPoorer physical health status

Findings

Lifetime Prevalence of TBI-53%, more common among men than women surveyed

Rates 5 or more times greater than the 8.5% lifetime prevalence in general population and consistent w/ prison studies

Briefly: Facts and Figures-What is The Problem?

Alcohol Use & TBI-IncidenceAnalysis of the Literature (Corrigan 1995)

Alcohol, the drug of choice-Corrigan and his colleagues report that for 70% of the individuals they work with who use substances, alcohol is the preferred substance

Intoxication at time of injury-7 studies looked at incidence of intoxication (BAL equal or exceeding 100mg.dL)at time of injury. Intoxication ranged from 36% to 50%

History of Substance Abuse-Findings suggest that for adolescents and adults in rehabilitation following a TBI, as much as 60% of this population have histories of alcohol use or dependence.

TBI & Alcohol? Impact on Recovery, Studies Suggest…..

Alcohol may negatively affect the process of dendrite profusion thus impede ability of the remaining neurons to compensate for the neurons that have been damaged (Corrigan, NASHIA Webcast 2003)

Alcohol use after brain injury may increase the risk of seizure post TBI

Increased brain atrophy observed in patients with a positive BAL and or history of moderate to heavy pre-injury use (Bigler et al 1996 & Wilde et.al 2004)

TBI & Alcohol? Impact on Recovery, Studies Suggest…..

Kreutzer et al (1995) examined the alcohol use patterns, arrest histories, behavioral characteristics and psychiatric treatment histories of 327 individuals with TBI. Increases in abstinence rates were noted. However in relation to the uninjured population, analysis revealed high incidence of heavy drinking, pre- and post-injury among those with a history of arrest. History of arrest also associated with a greater likelihood of aggressive behaviors.

Lessons Learned-What brain injury professionals have and haven’t done to address the Brain Injury/ Substance Abuse Connection

Lessons Learned

“Honeymoon” effect-first year post TBI

Subsequent Substance Use and Abuse among individuals with a history of brain injury

Feedback from Individuals with TBI in Recovery

Collectively Lulled to Inaction by the “Honeymoon” Effect

Bombardier reports (1997) that in comparison with a separate medical patient sample, individuals with a recent TBI were more motivated to change their alcohol use. Motivational Interviewing was utilized and of 50 post TBI patients, 84% fell into the contemplation or action phases. Greater willingness to change was noted in those with alcohol involved injuries and higher daily consumption pre-injury

“Honeymoon” Effect

In 197 individuals treated at a Level I trauma center, alcohol use diminished in the first year following TBI (Bombardier et.al 2003)

Honeymoon Factors

Individual in an inpatient and/or highly structured outpatient setting resulting in detoxification

Physical and cognitive disabilities make access to substances difficult

Families are instructed to provide supervision due to physical needs and judgement concerns

Individual is remorseful over past use, related behavior, blames self for accident and vows to change

The Honeymoon is OverKreutzer and colleagues (1996)followed the pre-and post-injury patterns of alcohol and illicit drug use of 87 individuals at 8 and 28 months post TBI. Decline in use was noted at first follow-up. Use at second follow-up were similar to pre-injury use

Subsequent Substance Use/Abuse Among Individuals with a History of Brain Injury-Characteristics

MaleYounger ageHistory of substance abuse prior to

injuryDiagnosis of depression since TBIfair/moderate mental healthbetter physical functioning (Kreutzer

1996, Horner et.al 2005)

Subsequent Substance Use/Abuse Among Individuals with a History of Brain Injury

5-10% of those with TBI develop substance abuse problems after their injury (NASHIA Webcast 2001)

“A person with a preinjury history of two drinks a day would not have had a reason to seek alcohol-related treatment before his or her accident. But once that same person becomes brain-injured, the continuation of that drinking pattern has the potential to cause major problems” Robert Karol, Ph.D.

Co-Occurring with Subsequent Use…..

Worse employment outcomesMore likely to be living alone &

isolatedGreater criminal activityLower subjective well-being or life

satisfaction (NASHIA Webcast 2001)

Feedback from Individuals in RecoveryThe researchers at the Research and Training Center on Community Integration of Individuals with Traumatic Brain Injury at Mt. Sinai in New York asked individuals with TBI, what are the factors involved in “kicking the habit”

What They said…..

Early treatment for those identified as known substance abusers

Pay attention to the covert drug usersChallenge of redefining new self and life

doubled with TBI sequela and substance abuse issues

Hard to know where to find support, with TBI community or substance abuse community

What They said…..To stay clean; find the right 12-step program, change “persons, places and things” that trigger use, spirituality, pets.

Techniques for change Recommended for use with individuals with a history of brain injury

Stages of Change, Prochaska and DiClemente cited by Corrigan 1999 Motivational Interviewing Based on the work of W. R. Miller , adapted by Corrigan& Successive ApproximationUtilized by Pathways Inc. Debra Fulton Clark

How to Utilize Substance Abuse Education & Intervention with individuals with Brain Injury:Tips for Human Service Professionals

The “Big” PictureBrain storm with group ( or individual)What do you know about substance

abuse, the brain and brain injury?What do you want to know about

substance abuse, the brain and brain injury?

Have a “quiz “ on hand to engage interest

(building motivation to change, moving from Precontemplation to Contemplation)

Sample Brain Injury and Substance Abuse quiz questions- (verbally or pen/paper)

In 1998, the cost of alcohol abuse in the United States was estimated to be $184.6 billion True or False

If there are alcoholics in your family tree, you are at risk for alcohol abuse, even if you were adopted and raised by nondrinkers. True or False Gold 2005

Sample Quiz Continued...

Addiction is a) brain disease b) a moral failing

Alcohol use after brain injury may increase the risk of seizures. True or False

5%-10% of people with brain injury develop substance abuse problems after their injury. True or False

Discussion Based on the “Quiz”

Review the correct answersAsk for other thoughts,

knowledge and experiences regarding substance abuse

Provide group with “Messages to Share” information sheet

Discuss the “Messages to Share”

Messages to ShareDrinking After Brain Injury Adapted from Bogner and Lamb-HartOhio Valley Center

People who use alcohol or drugs after TBI don’t recover as fast as those who don’t

Any injury related problems in balance, walking or talking can be made worse by using drugs or alcohol

People who have had a brain injury often say or do things without thinking first, a problem made worse by using alcohol or drugs

Brain injuries cause problems with thinking, like concentration or memory, and alcohol makes these worse

Messages to ShareDrinking After Brain Injury Adapted from Bogner and Lamb-HartOhio Valley Center

After a brain injury, alcohol and other drugs have a more powerful effect

People who have had a brain injury are more likely to have times when they feel sad or depressed and drinking or doing drugs can make these problems worse

After a brain injury, drinking alcohol or taking drugs can increase the risk of seizure

People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury

Suggestions

The “Quiz” and “Messages to Share” can be done with a group or with one or two individuals

Any one of the messages can be explored in depth, with the facilitator sharing the research on a specific message or messages

The group can digress at any time to a discussion of the brain’s functioning and anatomy-relate that information to impact of SA

Screening Tools

CAGE Questionnaire

Brief Michigan Alcoholism Screening Test (BMAST)

AUDIT

CAGE (Ewing 1984)

Have you ever felt you should Cut down in your drinking?

Have you ever felt Annoyed by someone criticizing your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (Eye opener)

CAGEResearchers at Mt. Sinai found the specificity

of the CAGE for alcohol abuse both pre-and post-TBI to be high, 96% & 86%, respectively. (2004)

CAGE is very ease to administer & sensitive with TBI population (Fuller et al 1994)

CAGE’s brevity allows for easy integration into intake interviews

Limitation of CAGE- lacks consumption questions needed to determine individuals with current versus lifetime of alcohol-related problems (Bombardier & Davis)

BMAST (Selzer et.al)

(2) Do you feel you are a normal drinker? * (2) Do friends or relatives think you are a

normal drinker?* (5) Have you ever attended a meeting of

Alcoholics Anonymous? (2) Have you ever lost friends or

boy/girlfriends because of drinking? (6) Have you ever neglected your

obligations, your family or your work for two or more days in a row because you were drinking?

BMAST (Selzer et.al)

(2) Have you ever had delirium tremens (DTs), severe shaking, heard voices, seen things that weren’t there after heavy drinking?

(5) Have you ever gone to anyone for help because of your drinking?

(5) Have you ever been in a hospital because of drinking?

(2) Have you ever been arrested for drunk driving or driving after drinking?

* Negative responses are alcoholic responses

BMAST BMAST is very ease to administer & sensitive with TBI

population (Fuller et al 1994) BMAST is nearly as sensitive as the complete MAST,

using a cutoff of three or more among individuals with TBI

Simple true-false format Sensitive to less severe alcohol problems Well researched Limitations-long, some questions may be difficult to

understand, and some questions may be offensive. (e.g., “are you a normal drinker?”) (Bombardier & Davis 2001)

Alcohol Use Disorders Identification Test (AUDIT) (World Health Organization)

3 items on alcohol consumption, e.g How often do you have a drink containing alcohol?

4 items on alcohol-related life problems, e.g., How often during the last year have you failed to do what was normally expected from you because of drinking?

3 items on alcohol dependence symptoms e.g., How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

AUDIT Pros & Cons (Bombardier & Davis 2001)

Takes 2-3 minutes to administer, 1 minute to score

Identifies alcohol abuse, not just dependence Sensitivity of the AUDIT is above 90%Developed multi-nationally-materials available

in several languages including Spanish Can be used to provide specific feedback

regarding riskLimitations-length, not used widely with

individuals with TBI at this time, but is recommended by the authors

Additional Screening Tools

Substance Abuse Subtle Screening Inventory-3, Useful for screening for alcohol abuse and the face valid drug sub-scale may be useful for screening for drug abuse in individuals with TBI. (Ashman et. al. 2004)

Addiction Severity Index-R (very long)Quantity-Frequency-Variability Index,Well

researched self-report questionnaire. Quantitative measure of alcohol use

How to Use Screenings(Depending on your agency, consumers, how your program is organized)

At intake to program servicesIndividually as part of initial

assessment early on in programAs part of a group activityAs part of ongoing individual

counseling/therapy sessionsTo be repeated as part of discharge

preparations

Implementing Interventions

Accessing and Making Accessible 12-Step Programs in the Community

Suggestions for rehabilitation providers and other human service professionals

AA 12-Steps, Modifiedfor Individuals with TBI (Peterson 1988)

We admitted we were powerless over alcohol; that our lives had become unmanageable

Came to believe that a Power greater than ourselves could restore us to sanity

Admit that if you drink or use drugs your life will be out of control. Admit that the use of alcohol and drugs after having a brain injury will make your life unmanageable

You start to believe that someone can help you put your life in order. This someone could be God, an AA group, counselor, sponsor, etc.

For Individuals with Brain Injury Provide concrete examples of AA

Share AA literature, big book, the story of Bill W

Show a movie or TV depiction of an AA movie e.g. Clean and Sober a 1988 movie with Kathy Baker, Morgan Freeman and Michael Keaton, My Name is Bill W. a 1989 movie with James Gardner and James Wood


Show scenes of AA/NA meetings from HBO’s The Wire, the character “Bubbles” takes steps towards sobriety

Ask a consumer in recovery to come and speak to a group


Covert the 12 steps into pictures, can be a group activity or individual activity-good for individuals with impaired language skills/concrete thinkers (Reynolds and Murrey 2006, in Alternative Therapies in the Treatment of Brain Injury and Neurobehavioral Disorders, A practical guide, published by The Haworth Press)

If feasible, encourage attendance at the Humanim AA meeting for individuals with BI

New Beginnings Group ofAlcoholics Anonymous

What: An open meeting of AlcoholicsAnonymous

Type of Meeting: Speaker

When: Wednesday at 6:30 pm

Where: Humanim, located behind the MVAemissions inspection station at 6335 Woodbine

Ct. in Columbia, MD 21046

Contact: For more information call Martin K. at(443) 756-3419

A Letter to Potential AA & NA Sponsor (McHenry & members of the Task Force on Chemical Dependency, NHIF 1988)

Intended as an educational introduction to a potential sponsor

Review common cognitive and emotional sequela of TBI

Make compensatory strategies suggestions, e.g. poor memory can be supported by journals and datebooks

Suggestions to Personalize Letter

Shorten it by focusing on the issues pertinent to the individual

Prepare the letter with the individual, include their input in terms of which strategies and supports work for them

Suggestions to Personalize Letter…..

If appropriate, obtain releases so the sponsor can contact the mental health/substance abuse professional

Provide updated information regarding local and state TBI information and referral resources

Additional Tips for Rehabilitation Providers and other Human Service Professionals Working with Individuals with TBI

Review if available any neuropsychological or neuropsychiatric records

Attend 12-Step meetings with a “buddy” or staff member, review meeting highlights

“90 meetings in 90 days” may be too stimulating or fatiguing after a TBI, balance so benefits of structure, social group can be gained

If the individual plans to share at a meeting, have them jot down before hand what they want to say on an index card


Avoid approaches that are confrontational (Sparadeo, NASHIA Webcast 2003)

Insight oriented treatment approaches may not work for individual’s whose thinking is very concrete after a brain injury

Offer “The Big Book” and other books with a recovery or inspirational theme on tape

“Where the body goes, the mind follows”, “One day at a time” etc. powerful & easy to recall reinforcing messages


Use “Change Plan” & “Staying Clean, Staying Sober” Worksheets

Prepare for slip ups-”Emergency Plan”& “Personal Emergency Plan: Lapse”

Judicious use of drug testing

Strategies to Compensate for Brain Injury Related Cognitive Barriers

Adapted from the Ohio Valley Center for Brain Injury Prevention and Rehabilitation

1998

Try to determine person’s unique learning style

Ask how well she writes, evaluate via samples

Ask about & observe attention span in busy versus quiet environments

If unable to speak or speak clearly, inquire as to alternate methods, e.g. writing, gesturing

Evaluate comprehension of written and spoken language

Help Compensate for Unique Learning Style

Modify written material to make it concise

Paraphrase concepts, be concrete

Encourage of note taking for future review

Enlist support system to reinforce messages

Help Compensate for Unique Learning Style

Don’t assume carryover or generalization of material, especially novel information

Repeat, review, rehearse, review, rehearse…….

Provide direct feedback regarding inappropriate behaviors

Let person know a behavior is inappropriate, do not assume he knows and is choosing to do so anyway

Provide straightforward feedbackRedirect tangential or excessive

speech, including a predetermined method of signals for use in groups

Be cautious concluding that an underlying emotional state is the basis of an observed behavior

Do not presume that an underlying emotional state is the basis of an observed behavior

Be aware that unawareness of deficits can arise as a result of specific damage to the brain and may not always be due to denial

Be cautious concluding that an underlying emotional state is the basis of an observed behavior

Confrontation shuts down thinking and elicits rigidity; roll with resistance (principles of Motivational Interviewing are highly recommended)

Do not just discharge for noncompliance; follow up and find out why someone has not showed up or otherwise not followed through

Brain Injury Rehabilitation Providers and Professionals…………...

Never underestimate the value your patients place on your opinions and advice

You don’t have to be an Addictions Counselor to speak from your knowledge and expertise regarding the impact of substances on the rehabilitation work you are doing with the patient, for example….

“As your PT, I need to let you know that drinking will impact your balance and we want to do all we can to minimize the risk of fall”

“As your speech therapist, I recommend you do not drink alcohol because it will make your articulation, memory and new learning abilities worse”

Brain Injury Providers and Professionals…..

Outreach to substance abuse providers and professionals in your geographic area

Share your knowledge about how to support individuals with brain injury related cognitive, behavioral and physical challenges

Create an “ad hoc” team for those individuals with a dual diagnosis of brain injury and substance abuse

Substance Abuse Providers and Professionals…………...

Understanding how to support individuals with a history of brain injury can make a huge impact on treatment participation and successful recovery

Integrate the suggested strategies across the board

Strategies can assist those not only with a history of brain injury, but individuals with a developmental disability, alcohol related cognitive impairment in addition to those who are anxious and depressed

Substance Abuse Providers and Professionals…..

Outreach to brain injury providers and professionals in your geographic area

Share your knowledge on substance abuse, addiction and treatment.

Create an “ad hoc” team for those individuals with a dual diagnosis of brain injury and substance abuse

Where Do We Go From Here?Look to the Innovators

John Corrigan Ph.D.-currently conducting a study on the efficacy of the Dartmouth Evidence Based Practice Supported Employment Model with individuals with brain injury and co-occurring conditions-results should greatly benefit the field

Ken Minkoff MD & Christine Cline MD.- their model for treating individuals with co-occurring psychiatric and substance abuse disorders might have application for individuals with co- occurring brain injury and substance abuse

“In my judgement such of us who have never fallen victims (to alcoholism) have been spared more by the absence of appetite than from any mental or moral superiority over those who have”-Abraham Lincoln to the Washington Temperance Society, Springfield Illinois 1842

References

Alcohol, Alcohol Abuse and Alcohol Dependence CME Resource training course, Mark S. Gold, MD www.netce.com/course.asp?Course=651

Corrigan JD. (1995). Substance Abuse as a Mediating Factor in Outcome from Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation Vol. 76, April: 302-309

Bombardier, CH., Temkin, NR., Machamer, J., Dikmen SS.(2003), The Natural History of Drinking and Alcohol-Related Problems After Traumatic Brain Injury Archives of Physical Medicine and Rehabilitation Feb;84(2):185-91.

Bombardier C., Davis, C. (2001). Screening for Alcohol Problems Among Persons with TBI. Brain Injury Source. Fall 16-19.

Corrigan J., et. al (1998) Utilities for Community Professionals. Ohio Valley Center for Brain Injury Prevention and Rehabilitation

References

Bombardier C., Davis, C. (2001). Screening for Alcohol Problems Among Persons with TBI. Brain Injury Source. Fall 16-19.

Corrigan J., et. al (1998) Utilities for Community Professionals. Ohio Valley Center for Brain Injury Prevention and Rehabilitation

Murrey, J. Gregory (2006). Alternate Therapies in the Treatment of Brain and Neurobehavioral Disorders, A practical guide.Published by The Haworth Press Inc.

Slide 18 adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

ResourcesUniversity of Kentucky, on line training for

professionals, “Substance Abuse, Mental Illness and Brain Injury, A Guide for Making Accommodations for Treatment” cdar.uky.edu/TBI/welcome.html

Ed Ross of the ICD in NYC, conducting ongoing trainings across the state to mental health and substance abuse professionals regarding brain injury. For more information contact [email protected].

Resources

The Ohio Valley Center for Brain Injury Prevention and Rehabilitation continues to conduct research and training regarding brain injury, substance abuse and building capacity within the community to work with individuals with brain injury. www.ohiovalley.org

Pathways Inc., Brain Injury Recovery Services, Hollywood Maryland, contact Debbie Fulton Clark for details regarding how substance abuse treatment can be integrated into a brain injury community re-entry program. [email protected].

Kenneth Minkoff, MD. Www.kenminkoff.com. Regarding co-occurring substance abuse and psychiatric illness

Staff Training Opportunities

The Michigan Department of Community HealthWeb-Based Brain Injury Training for Professionals This free training consists of 4 module that take an estimated 30 minutes each to complete. The purpose of the training is twofold, to “ensure service providers understand the range of outcomes” following brain injury and to “improve the ability of service providers to identify and deliver appropriate services for persons with TBI”

The New York State Office of Alcoholism & Substance Abuse Services-OASAS www.oasas.state.ny.us/tbi/index.cfm

Websites of Interest

www.ohiovalley.org, The Ohio Valley Center for Brain Injury Prevention and Rehabilitation. Specific information and fact sheets on substance abuse and brain injury

casaa.umn.edu/intro.asp, Center on Alcoholism, Substance Abuse, and Addictions at the University of New Mexico. Visitors can email staff and faculty who specialize in different aspects of substance abuse treatment.

Websites of Interest

Lib.adai.washington.edu/dbtw-wpd/exec/dbtwpub, Alcohol & Drug Abuse Institute at the University of Washington in Seattle. Visitors can download assessment instruments and guides for use.

NEW!!!!! “Rethinking Drinking” from the National Institutes of Health. This is an interactive website that aims to educate individuals about alcohol use and abuse. It provides screening tools and change plans, supports and resources.

www.rethinkingdrinking.niaaa.nih.gov.

A Product of the Maryland TBI Partnership Implementation Project, a collaborative effort

between the Maryland Mental Hygiene Administration, the Mental Health Management

Agency of Frederick County and the Howard County Mental Health Authority

2006-2009

Acknowledgement…..

Thank you to John Corrigan Ph.D and colleagues at the The Ohio Valley Center for Brain Injury Prevention and Rehabilitation for their support of the Maryland Traumatic Brain Injury Projects.

Anastasia Edmonston [email protected]

Support is provided in part by project H21MC06759 from the Maternal and Child Health Bureau (title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Service

Thank you!

Documents

Substance Abuse and Brain Injury Anastasia Edmonston MS CRC TBI Projects Director Maryland Mental Hygiene Administration